WEST VIRGINIA NURSING ASSISTANT EVALUATION …

1 WEST VIRGINIA . NURSING ASSISTANT EVALUATION APPLICATION. TO BE REGISTERED FOR TESTING, YOU MUST BE LISTED AS TEST ELIGIBLE ON THE WEST VIRGINIA NURSING ASSISTANT ONLINE. VERIFICATION AT . ATTACH OFFICIAL VERIFICATION TO APPPLICATION. Part 1: General Information CORRECT FEES MUST ACCOMPANY THIS APPLICATION. Name (legal name) _____ Soc. Sec. No. _____. (As on social security card) Last First Middle (XXX-XX-XXXX). Name on application must exactly match admission ticket, photo ID and social security card (admission ticket, photo ID, & unaltered original non-laminated social security card required to enter test site).

2 SOCIAL SECURITY NUMBER DISCLOSURE: Disclosure of your social security number should only be made if obtained from you in accordance with Section 7 of the Privacy Act of 1974. Your disclosure is voluntary for the purpose of internal identification, and may be used to verify information on your application, (class admissions and completions, competency EVALUATION testing, re-registration and reciprocity applications, etc), to verify certification with another state's certification authority, for exam identification, for identification purposes in national disciplinary databases or as the basis of a disciplinary action against you.

3 In accordance to the 42 CFR (c), failure to provide requested information may result in your application being returned, or a delay in processing. Maiden Name:(required) If left blank, above name will be used. _____. Mailing Address _____. _____. Home phone:(xxx-xxx-xxxx) _____ Birth date (MM/DD/YYYY) _____. Part 2: EVALUATION Choices CORRECT FEES MUST ACCOMPANY THIS APPLICATION. NEW CANDIDATE, RESCHEDULING, & REFRESHER RE-TAKES. _____Written & Skills Exams(computer-based) $125 _____Written(computer-based) $55. _____Oral & Skills $160 _____Skills $70. _____Oral $90.

4 PART 3: SPONSOR INFORMATION- WHO IS PAYING FOR YOUR EXAM & WILL RECEIVE YOUR ADMISSION TICKET. Sponsor Name _____. Address _____Phone _____ Fax_____. _____ Email _____. Sponsoring Facility Contact _____ email_____. *If you do not have a sponsor, write SELF in the blank and the admission ticket will be sent to your home address. PART 4: TRAINING PROGRAM (WHERE YOU TOOK YOUR TRAINING PROGRAM). Was this a refresher course? _____ YES _____ NO. Are you a RN/LPN challenge? _____YES _____ NO (Must have approval letter from WV NURSING ASSISTANT program). Training Program _____Training Code _____.

5 Address _____Phone _____. _____. When did you complete this training course: Date (MM/DD/YYYY) _____. Page1of 3. Instructor _____ 4/2018. Part 5: Location of EVALUATION Requested Test Site _____Date (MM/DD/YYYY) _____. Part 6: Special Testing Needs _____I do not require special accommodations for the EVALUATION . _____I DO require special accommodations for the EVALUATION *. Please explain _____. _____. Applications must be received at PHD, LLC's office with payment two weeks prior to testing date and candidate must be listed as test eligible with the WV Nurse Aide Registry.

6 At test site, candidates must present their admission ticket(PHD, LLC will sent to sponsor 1 week prior to test), a current photo ID, and their unaltered original social security card(laminated social security card not accepted) to enter test site. If you are pregnant or injured, a doctor's release must arrive at PHD, LLC's office prior to 2:00 pm the day before the test stating NO RESTRICTIONS dated for the test date. Rescheduling You must notify PHD, LLC by noon at least five (5) days before the examination date to reschedule. If you do not call PHD, LLC at least five business days before your examination date to reschedule and do not show up on your scheduled examination date, your fee will NOT be refunded and cannot be transferred to a new examination date.

7 CORRECT FEES MUST ACCOMPANY THIS APPLICATION. _____ _____. Candidate Signature Date _____ _____. If Under 18, Parent of Guardian Signature Date NO PERSONAL CHECKS. Payment Options Certified Check Facility Check Money Order VISA MC Discover AMX. Credit Card #_____ Expiration Date (MM/YYYY)_____ Security code _____. Print/Type name as it appears on credit card_____. Amount to Charge Card $ _____ Phone number (XXX-XXX-XXXX) _____. Credit Card Mailing Address Street_____. City _____ State_____ Zip Code_____. Authorized Card Holder Signature_____ Date _____. Mail application and correct fees to: Professional Healthcare Development, LLC.

8 Box 399. Ona, WV 25545. Phone 304-733-6145. Fax 304-733-6146. CORRECT FEES MUST ACCOMPANY THIS APPLICATION. Page 2 of 3 4/2018. KEEP THIS PAGE. For all policies and procedures, please refer to the following: Professional Healthcare Development, LLC's The Sponsor/Candidate Handbook also HANDBOOK FOR THE WEST VIRGINIA REGISTERED LONG-TERM CARE NURSE. AIDS and CRITERIA FOR APPROVAL OF EDUCATION PROGRAMS AND GUIDELINES FOR THE TRAINING OF LONG- TERM CARE NURSE AIDES IN WEST VIRGINIA . Rescheduling You must notify PHD, LLC by noon at least five (5) days before the examination date to reschedule.

9 If you do not call PHD, LLC at least five days before your examination date to reschedule and do not show up on your scheduled examination date, your fee will NOT be refunded and cannot be transferred to a new examination date. You must bring the following items with you to the test site: Incorrect or improper documentation will result in not being admitted to test site and fees being forfeited. You must bring your admission ticket, current photo ID, and original unaltered Social Security card. Name and Social Security number on admission ticket must match photo ID and SS card (laminated social cards not accepted).

10 If you arrive without the proper documentation, you will not be able to take the exam and you will lose your fees. You may use the substitute ID (in place of the photo ID only). Your instructor will fill out part of it and you take it to the test site with you. Take care of this BEFORE the day of your exam. Three (3) No. 2 pencils and eraser A watch with a second hand (no sharing of watches is permitted). No other materials will be allowed. Remember that all of the test materials, test questions, etc., are the property of PHD and may not be copied or given to anyone other than the candidates the day of the exam.